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128 Cards in this Set
- Front
- Back
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The separation or opening of wound layers. It is a failure of wound healing in which the surgical wound separates and opens to the fascial level.
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Dehiscence |
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A scab or dry crust that results from excoriation of the skin.
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Eschar |
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The separation of wound layers with the protrusion of abdominal organs through the layers.
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Evisceration |
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Soft, pink, fleshy projection of tissue that forms during the healing process in a wound not healing by primary intention.
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Granulation tissue. |
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Induration of collagen deposits beneath the skin extending about 1 cm on each side of the wound.
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Healing ridge.
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Termination of bleeding by mechanical or chemical means or by the coagulation process of the body.
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Hemostasis |
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What is a Hemovac drain?
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A closed drain system used in wound care. |
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What is irrigation?
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The gentle washing of an area with a stream of solution.
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What is a Penrose drain?
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An open drain system.
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What is primary intention?
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The primary union of the edges of a wound, progressing to complete scar formation with granulation. In this type of healing, the wound heals quicker, tissue loss is minimal, and eliminates the need for dressing. Usually a result of a clean surgical incision. (Made by a Dr and closed by a Dr)
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What is secondary intention?
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Wound closure where the edges are separated, granulation tissue develops to fill the gap and epithelium grows over the granulation, producing a larger scar then seen in primary intention. Usually a result of a severe laceration or massive surgical intervention with skin loss. (Gap between edges)
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What is tertiary intention?
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It is wound healing that occurs when surgical wounds are not closed immediately but left open for 3 to 5 days to allow edema or infection to diminish.
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What is the basal layer?
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The innermost layer of the epidermis, also called the stratum germinativum. |
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What are the four phases of wound healing?
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Hemostasis, inflammatory, proliferative, and maturation phase. |
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What occurs during the hemostasis phase of wound healing?
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Blood vessels constrict, clotting factors activate, and coagulation occurs. Growth factors are released by platelets to begin wound healing. |
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What occurs during the inflammatory phase of wound healing? |
Vasodilation occurs and allows for plasma and blood cells to enter the wound site. Leukocytes begin wound cleaning. Cleaning occurs. Goal is to control infection! |
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What occurs during the proliferative phase of wound healing? |
Epithelialization (epidermal construction) begins and new granulation tissue is formed. Contraction and new capillaries are formed as the wound close. |
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What occurs during the maturation phase of wound healing?
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Collagen is remodeled to become stronger and provide tensile strength to the wound. The outer appearance in an uncomplicated wound will be that of a well-healed scar. |
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What are some factors that affect wound healing?
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-Patient nutritional status -Infection status -Underlying medical conditions (Diabetes) -Use of immunosuppressants -Age (higher=slower) |
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What type of healing is this?
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Primary
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What type of healing is this?
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Secondary
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In wound care, if there is brown/black eschar tissue, what must be done?
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This type of tissue must be removed via various methods such as sharp or chemical debridement. |
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In wound care, if there is yellow or sloughing, what must be done?
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A moisture retentive tissue should be used in patients with a low risk for infection. The dressings used can be hydrocolloids, hydrogels, or alginates. |
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In wound care, if there is a red wound with granulation, what must be done? |
Keep it clean and moist to minimize damage to healing tissue. |
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What is NPWT?
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Negative pressure wound therapy that is used to facilitate healing via suction and to collect wound fluid. This method includes the use of a hemovac. |
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When performing wound care, what infection control procedures must occur?
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Hand hygiene, clean gloves, and in some cases sterile technique. |
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How is irrigation performed?
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You muse always cleanse in the direction from the least contaminated to the most contaminated (away from wound). When irrigating you must verify that all solution flows from least contaminated to most contaminated (away from wound). |
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When should the irrigation solution be sterile?
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When cleansing a post-op wound. |
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When irrigating wounds, what should the pressure be? |
Between 4 to 15 psi.
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In what situation would you use a high-pressure irrigation, and what type of delivery system would you use? |
In the presence of necrotic tissue, debris, or other particulate. Also in the presence of moderate to large amounts of exudate. A 35-mL syringe or 19-gauge angiocatheter is recommended. |
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In what situation would you use a low-pressure irrigation, and what type of delivery system would you use? |
In the presence of granulation tissue with none to minimal serous or serosanguineous exudate. Pouring directly from the bottle or use of a piston or bulb syringe is recommended. |
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What are the signs of infection in a wound?
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Redness, warmth, drainage, pain, tenderness, and an unusual odor. |
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What is a superficial incision infection? |
Infection of the skin or subcutaneous tissue at a surgical incision site. |
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What is a deep incision infection? |
Infection involving the organs or body cavities in the are of a surgery. |
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What are factors that contribute to dehiscence? |
Anemia, malnutrition, obesity, and use of steroids. |
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If you notice evisceration, what should you do?
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It is a medical emergency. You need to cover the wound with a moist sterile saline dressing, notify the surgeon immediately, and prepare the patient for emergency surgery. |
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What are the parameters for a complete wound assessment?
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-Location -Wound type (Surgical, pressure, trauma) -Extent of tissue involvement (full or partial thickness, pressure ulcer stage, etc.) -Type and percentage of tissue wound base and amount (granulation, slough, escar) -Wound size (WxDxL) -Wound exudate description -Odor -Periwound area -Pain |
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What is a partial thickness wound?
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A wound involving only the epidermal layer. |
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What is a full thickness wound? |
A wound involving the epidermal and dermal layer. |
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What is a healing ridge? |
An accumulation of new tissue along the wound border. It will appear as firmness beneath the skin that extends about 1 cm on each side. |
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How is length measured? |
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How is width measured? |
Side to side, or 9 o'clock to 3 o'clock.
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What are signs of delayed wound healing? |
Wound edges are rounded toward the wound bed. |
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When performing a wound irrigation, how far above the wound should you be?
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1 inch from syringe and 12 inches if a shower spray is used. |
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Can a NAP do wound irrigation?
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They can perform a clean wound irrigation, but not a sterile wound irrigation. |
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What is Hydrogel wound dressing? |
Composed of water or glycerin based polymers, this type of dressing provides moisture to a wound bed. This type of wound dressing is available in sheets or a gel and is used in autolytic debridment. This type of wound dressing is indicated in partial and full thickness wounds, wounds with dry to minimal exudate, and in necrotic wounds. Brands include Skintegrity, Elasto-Gel, and Vigilon. |
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What is Alginate wound dressing? |
A highly absorptive product that are retentive gel or a fiber-gelling dressing. It is available in pads or ropes. It is used in moderate to heavy wound exudate or to cause hemostasis. Brands include Restore Calcicare, SeaSorb, and Algisite M.
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What are Foam wound dressings?
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Used for absorption and available in adhesive or non-adhesive forms. They are used in the absorption of moderate to heavy exudate. Brands include Biatain, Hydrocell, and PolyMem. |
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What are Gauze wound dressings? |
Used for absorption and come in woven or non-woven, cotton or synthetic, sterile and non sterile forms. They are used for protection of surgical wounds, absorption of minimal to heavy exudate, and to deliver solution to a wound. Brand names include Curity Gauze Sponges, KERLIX Super Sponge, KLING gauze rolls, and NU GAUZE packing strips. |
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What are Hydrocolloid wound dressings? |
Made of gelatin, pectin, and carboxymethylcellulose particles suspended in adhesive base. These types of dressings are used to maintain a moist environment by forming a gelatinous mass. They are used for autolytic debridment. Brand names include DuoDERM, Exuderm, and Replicare. |
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What is autolytic debridement?
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Using moisture via a semiocclusive dressing to loosen non-viable tissue. |
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What is sharp debridement? |
Using sterile instruments to remove dead tissue. Only performed by the health care provider. |
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What is mechanical debridement? |
Using irrigation to remove or loosen dead tissue. |
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What is enzymatic debridement? |
Using enzymes (collagenase) to remove or loosen dead tissue. |
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Before sutures or staples are removed, what must occur?
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Order must be written by Dr. |
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If drainage accumulates in the wound bed, what occurs?
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Wound healing is delayed or compromised. |
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How much fluid can a JP drain collect?
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100 to 200 mL every 24 hours.
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How much fluid can a Hemovac drain? |
500 mL every 24 hours.
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Why would you pin drainage tubing to a patient's gown?
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In order to prevent tension on the tubing and insertion site.
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What must occur in order for a Hemovac to work?
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It must be compressed in order to create a vacuum. |
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What type of dressing would you need to control bleeding? |
A pressure dressing.
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What types of dressing would you use on a non-infected wound that is draining moderate to large amounts of exudate?
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Alginate, Gauze, or Foam (adhesive, hydrating, semiocculsive, primary, or hydrocolloid) dressing.
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What type of dressing is used for wound healing by primary intention with little drainage?
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Dry gauze.
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What is the primary purpose of moist to dry dressings? |
To mechanically debride a wound. |
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Which types of dressing provide a moist environment for wound healing?
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Hydrocolloid. |
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Which dressing have a high moisture content that cause swelling a retention of moisture and exudate?
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Hydrogel. |
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Which dressing is useful for 3rd degree burns, partial or full thickness wounds, shallow or deep wounds, dry to minimal wounds with no necrosis? |
Hydrogel. |
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Which dressing is recommended for the management of wound healing by primary intention with little drainage?
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Dry dressing. |
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What is the purpose of packing wounds?
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To fill dead space and avoid the potential of an abscess formation by a wound closing too soon. |
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What is tunneling?
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Channels that have formed and extend from any part of the wound through subcutaneous tissue or muscle. |
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How is normal saline made?
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8 teaspoons of salt in 1 gallon of distilled water. Must keep it refrigerated, and good for up to a month. Saline solution should be allowed to reach room temperature before use. |
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When should topical anesthetics be applied for wound care?
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30-45 minutes prior. |
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What can occur if sutures are left for more than 14 days?
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Suture marks may be left. |
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When should sutures be removed?
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7 to 14 days after surgery, if healing has been adequate. |
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When should a wound culture be performed?
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If there is an increase in the amount and consistency of the drainage and if there is a new presence of odor, these factors may indicate a wound infection and antibiotics may be required.
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How is a wound culture collected?
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From fresh exudate at the center of the wound after old drainage has been removed. |
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How is an aerobic wound culture obtained?
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Take a swab from a culture tube, insert the tip into the wound in the area of drainage, and rotate it gently. |
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How is an anaerobic wound culture obtained? |
Take swab from culture tube, swab deeply into draining body cavity, and rotate gently. Insert tip of syringe with needle and aspirate 5 to 10 mL of exudate, attach 19 gauge needle, and expel air and inject into special culture tube. |
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Where should you cut when performing a suture removal?
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Close to the skin and not close to the not. This prevents the contaminated portion of the suture (exposed) from entering the uncontaminated area (below the skin). |
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What is a Penrose drain?
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An open drain system that deposits drainage outside the wound zone onto gauze dressings that cover the wound. |
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What is angiogenesis?
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The formation of new blood vessels. |
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What is dead space?
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A cavity remaining in a wound. |
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What is epithelialization?
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The process by which epidermal cells migrate over the surface of a wound to close the top or "resurface" the wound.
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What is erythema?
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Redness or inflammation of the skin or mucous membranes. Result of dilation and congestion of superficial cavities. |
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What is excoriation?
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An injury to the surface of the skin or other part of the body caused by scratching or abrasion. |
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What is exudate?
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Any fluid that has been extruded from a tissue or its capillaries, more specifically because of injury or inflammation. It is characteristically high in protein and WBCs. |
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What is granulation?
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The presence of red, granular, moist tissue that appears during the healing of open wounds; type of tissue containing new blood vessels that bleed readily.
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What is hydrocolloid?
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An adhesive, moldable wafer made of a carbohydrate-based material, usually with a waterproof backing. This dressing is usually impermeable to oxygen, water, and water vapor, and has some absorptive properties. |
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What is neovascularization?
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The process by which the vascular network in a wound is generated. Also called angiogenesis. |
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What is an occlusive dressing?
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A dressing that prevents air from reaching a wound or lesion and retains moisture, heat, body fluids, and medication.
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What is a pressure dressing?
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A temporary treatment for the control of excessive bleeding. These types of dressings require elastic bandages to maintain the pressure and may also require the application of sandbags adjacent to the dressing to augment pressure.
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What is a primary dressing?
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A dressing that comes in direct contact with the wound bed. |
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What is a secondary dressing?
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A dressing used to cover or hold primary dressings in place.
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What is a wound vacuum-assisted closure?
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A type of therapy that speeds wound healing by applying localized negative pressure to draw the edges of a wound together.
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What are disadvantages to gauze dressing?
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It may adhere to healthy tissue causing injury when removed. May leave lint fibers and may interfere with wound healing once it dries out. Do not use in granulating wounds.
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When is a transparent dressing appropriate?
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For prophylaxis on high-risk intact skin, superficial wounds with minimal or no exudate, and eschar-covered wounds when autolysis is indicated and safe. |
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During insertion of an NG tube, why do we have the patient swallow?
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Sipping or swallowing water aids the passage of the NG tube into the esophagus by closing access to the trachea. |
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A patient who had intestinal surgery yesterday has a nasogastric tube for gastric decompression. The patient is nauseated, and his abdomen is distended. The nurse irrigated the tube, but met resistance. What action should the nurse take?
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Check for kinks in the tubing. Turn the patient onto the left side to prevent the tube from touching the stomach lining. Repeated resistance should be reported to health care provider. |
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What could coughing indicate when inserting an NG tube?
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The tube may have entered the larynx and obstructed the airway or the tube may have coiled itself in the back of the throat. |
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Established standards for routine replacement of IV catheters and IV administration sets have recommended a maximum of ______ hours to reduce IV fluid contamination and prevent catheter site complications.
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72 |
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What should the nurse do once she recognizes that the patient has phlebitis at his IV site?
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Discontinue infusion, place a moist warm compress over the site.
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The nurse caring for a patient receiving IV fluids knows that the current recommendations for changing the tubing on a continuously running IV is:
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No more often than every 96 hours.
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The nurse is caring for a patient diagnosed with pneumonia who receives IV antibiotics every 8 hours. How often should the nurse change the primary intermittent IV sets?
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Every 24 hours.
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While assessing the patient's IV infusion, the nurse notes that it is infusing more slowly than it should be. What should the nurse do first?
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Check the position of the IV fluid and the extremity.
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The nurse is caring for a patient who has experienced hypovolemia secondary to acute vomiting and diarrhea. The nurse anticipates what type of intravenous fluid to be ordered by the health care provider?
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Hypotonic or isotonic solutions.
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What should the nurse do to decrease the potential for infection related to IV therapy? |
Palpate the insertion site daily through the intact dressing. |
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The nurse assigns nursing assistive personnel (NAP) to care for several patients with continuous IV infusions. Which of the following can NAP assist with?
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Informing the nurse if they notice anything abnormal.
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The nurse is preparing to administer medication using a volume-controlled administration set or Volutrol. Which action should the nurse do first?
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Open the clamp between the Volutrol and the main IV bag.
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The student nurse is preparing to administer an IV bolus medication through a small-gauge IV catheter. The student notes that there is no blood return on aspiration. Which action by the student should the nursing instructor question?
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Immediately stopping the IV infusion and removing the IV catheter.
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What is evidence based practice?
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A problem-solving approach to clinical practice that combines the conscientious use of research-based evidence in combination with clinical expertise and patient preferences.
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What is a gastrostomy feeding tube?
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A long, hollow, flexible tube inserted into the stomach through a stab wound in the upper left abdominal quadrant. |
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What is a Jejunostomy feeding tube?
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A hollow tube inserted into the jejunum through the abdominal wall for administration of liquefied foods.
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What is a nasogastric feeding tube?
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A small tube that is passed via the nares into the stomach. |
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When should an NG tube be placed via the mouth?
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If a patient is at risk for intracranial passage of the tube, or they have some sort of cranial trauma. |
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How is an NG tube measured?
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From tip of nose to earlobe and earlobe to xyphoid process of sternum. |
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Why should you encourage a patient who is having an NG tube procedure to move their chin towards their chest?
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This process closes off the glottis and reduces the risk for the tube entering the trachea. |
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When removing an NG tube, what should you have the patient do?
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Hold their breath. |
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When should you check feeding tube placement? |
Every 4-6 hours and before administering formula or medications through the tube. |
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How often should an NG tube be irrigated? |
Every 4-12 hours or per agency policy. |
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What is a Salem sump tube?
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A tube with a both a large and small lumen (air vent/blue pigtail) used to suction gastric contents. |
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What is a Levin tube?
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A tube with a single lumen used for NG tube feeding. |
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How high would the residual volume be in order to stop a gastric feeding?
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250-500 mL |
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What is the Hanson method of measurement?
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First you mark the 50 cm (20 inch) on the tube and then measure traditionally (nose to ear to xyphoid) and mark the tube. The tube insertion should be between the 50 cm mark and the traditional mark. |
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What is a guaiac test?
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A diagnostic test to detect blood in the stool. |
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What is melena?
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Darkening of the feces by blood pigments. |
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What is a vacutainer tube?
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A glass tube with a rubber stopper in which air has been removed to create a vacuum. |
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What foods may produce a false positive result in a stool specimen?
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Red meats within the last three days, medications containing iron, poultry, fish, and spinach. |
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What is the common site for an Allen test arterial blood gas draw?
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The radial and ulnar arteries. |
